HomeMy WebLinkAboutSeptic Pumping Slip - 1593 OSGOOD STREET 9/19/2016 _ Commonwealth Of Massachusetts
�= Giiy/Own O� N� � Andover
System- PUMP ng Record
Form 4
3DEP hss$rovided this form for use by local Boards of Health. Other forms may be used, t
information must be substantially the same as that provided here. Before using this form,
local Board of Health to determine the form They use. The System Pumping Record must 1
the local Board of Health or other approving authoriy within; 14 days from the pumping da;
accordance with 310 CM 15.351.
A_ Facility Info rlrflation
lmportant'When
11Gng our;or,s 1: System Location:
Or?the computer.
use only'he tab �J
key to move your Address —_._.__.-...._...__....._--•--....------- -...__.
cursor-do not __. ...__._.
use the return North Andover
—��-- -
key. G'tyrown ._.......... .................. ..>. ;
tat Zip CO&
2. System Owner.
i i ame --- _..__ .._......._
Address(if d�,-ierent from location) — '
State Zip Code
" Teteoho;te Nunoer -��--•"-"----'�-•�
Puff Ong Record
1. Date of Pumping Dat�eJ
—= --- �......... 2 Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) FV Septic Tank ❑ Tigh-LT an:r ❑ G;E
❑ Other(describe): - -..._.. __....- -......._...._..__.._ ._
4. Effluent Tee FiEter present? El Yes ❑ No I;yes, was it cleaned? ❑ Yes L
5. Condition of System:
6. System PumpdBy
u
i Name �SeDtjs, Vehice License Number
Stewa
Company — _...._ ......._ . .._... _
Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
n Date
Signawre of Receiving Facil?�y
_-
Da;e
j 25tor-.14.doc-03106